Beginning in July, PPO inpatient admission requests submitted through e-referral could be subject to clinical review

Starting July 9, 2018, inpatient acute care admissions for Blue Cross Blue Shield of Michigan commercial PPO members submitted through e-referral could be subject to clinical review. It’s a process that our facilities already follow for Medicare Advantage PPO inpatient acute care admissions and certain other members.

Clinical reviews like this become necessary as customers look for ways to reduce the amount they spend on medical services and as we try to consistently apply utilization management programs. For example, Blue Care Network, BCN Advantage^SM and Medicare Advantage PPO all have full inpatient review programs at Michigan hospitals.

These reviews also help us ensure that the patient stays are appropriate and billed correctly based on the patient’s diagnosis and condition.

With this inpatient review program, select facilities must submit medical inpatient stays through e-referral, and the requests could be reviewed and approved or pended for review by a clinician.

Additionally, behavioral health authorization requests and clinical reviews will continue according to the current process with the assigned behavioral health management vendor. However, inpatient admission authorization requests processed through New Directions** will be subject to full clinical review from the first day of admission and subject to non-approval. 

We’ve notified the affected facilities if their inpatient medical and behavioral health admissions require this new clinical review process.

If you’re not already familiar with e-referral or how the process works, contact your provider consultant for more information.

**New Directions is an independent company that provides behavioral health services for Blue Cross Blue Shield of Michigan.

We encourage you to join PGIP as a physician organization

We’re pleased to announce that we’ll accept applications for the Physician Group Incentive Program from new physician organizations from Aug. 1 through Aug. 31, 2018.

A PGIP physician organization consists of physicians working together to:

• Transform systems of care to effectively manage patient populations.
• Build the infrastructure needed to optimize, measure and monitor quality of care.

Physician organizations promote collaborative relationships and support the most cost-effective delivery of services to improve patient outcomes.

If you represent a physician organization and would like to join PGIP, send an email to valuepartnerships@bcbsm.com.

About PGIP
PGIP is an innovative provider program developed with input from doctors across Michigan to help improve the quality and efficiency of health care in the state. PGIP facilitates change through approximately 20 initiatives, including our nationally recognized Patient-Centered Medical Home program. It offers incentives for improving health care delivery to participating physicians, physician organizations and organized systems of care.

If you’re interested in participating in PGIP as an individual practitioner, click here. If you have questions about PGIP, contact your provider consultant. Not sure who that is? Visit the provider contacts page on our Blue Cross website. You’ll find more information in the middle of the page under the Provider consultants tab.

For more information
Visit these sites:

• Value Partnerships Overview page on our website
• Physician Group Incentive Program section of valuepartnerships.com

Reminder: Notify Medicare Plus Blue PPO members about their rights if post-acute care services will be terminated

As communicated in the June 2017 Record, post-acute care facility providers, whether contracted or non-contracted, must notify Medicare Plus Blue^SM PPO members about their rights to appeal a decision regarding termination of post-acute care services.

They must do this by complying with the requirements for the delivery of a valid Notice of Medicare Non-Coverage (Centers for Medicare & Medicaid Services form 10123-NOMNC). This notice must be delivered to the member no later than two days before service termination.

Post-acute care facility providers include skilled nursing facilities, comprehensive outpatient rehabilitation facilities and home health agencies.

Upon receipt of a Notice of Medicare Non-Coverage, or NOMNC, members or their authorized representative have the right to an expedited appeal to a CMS-delegated quality improvement organization. In Michigan, KEPRO^® is the delegated QIO.

When a member appeals

If the member or the authorized representative appeals to the QIO, the provider will receive an Expedited Appeal Documentation Request from the QIO. The provider must:

• Deliver a valid Detailed Explanation of Non-Coverage to the member.
• Respond to the QIO’s Expedited Appeal Documentation Request.
• Submit supporting documentation within the time frame set by the QIO.

According to the Medicare Claims Processing Manual, Chapter 30, “If a Qualified Independent Contractor (QIO) determines that a provider did not deliver a valid NOMNC to a beneficiary, the provider is financially liable for continued services until two days after the beneficiary receives valid notice, or until the effective date of the valid notice, whichever is later.” Providers may not bill members for the balance of these services.

CMS forms and instructions
To access NOMNC and DENC forms and instructions, click here.**

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

Outpatient facilities added to Medicare Plus Blue prior authorization program

Beginning June 28, 2018, Blue Cross Blue Shield of Michigan expanded its prior authorization program for Medicare Plus Blue^SM PPO specialty medical medications that are billed on a professional claim form to include outpatient facilities, place of service 19, 22 and 24. Currently, only place of service 11 is part of this program.

What you need to know

• Select specialty medications are covered under the Medicare Part B medical benefit. The selected medications are not self-administered and must be administered (via injection or infusion) by a doctor or health care professional. In addition to current place of service 11, expansion to include outpatient facilities with place of service 19, 22 and 24 will begin June 28, 2018.
• Place of service definitions:
• 11 – Provider office
• 19 – Off-campus outpatient hospital
• 22 – On-campus outpatient hospital
• 24 – Ambulatory surgical center
• Prior authorization is required for professional claims submitted on an HCFA 1500 form or ANSI 837P electronic submission with place of service 11, 19, 22 and 24. Facility claims submitted using UB claim submission aren’t in scope for this expansion.
• Providers must obtain prior authorization and verify patient benefits to be eligible for payment for administering these services. If a prior authorization isn’t obtained before services are rendered, the claim will be denied for no authorization on file. At that time, a provider may submit a retroactive authorization request within 90 days of the date of service. Patient must meet all requirements and have the necessary coverage for the claim to be payable.
• Authorization isn’t a guarantee of payment. Benefits and eligibility must be determined at the time services are rendered.

Providers will submit Part B medical drug requests for dates of service electronically through NovoLogix^®, a secure online tool, on or after June 28, 2018. NovoLogix allows providers to obtain real-time status checks on prior authorizations and to obtain immediate approvals for certain medications when patients meet the criteria. Submitting these requests electronically is the preferred method because it saves time and allows you to view the status of the request at any time. If your patient has an existing prior authorization for a provider-administered drug on file, an additional authorization for place of service 19, 22 or 24 isn’t required.

Future notifications will be sent that will provide you with the date when you can begin entering cases through the medical prior authorization e-tool if the patient doesn’t have an existing prior authorization on file with the provider’s office.

Look for more information about NovoLogix training and other program details in future issues of The Record and on web-DENIS.

Reminder: Update Provider Authorization Form when changes occur with your 835 ERA routing destination

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of our members. These safeguards include completion of a Trading Partner Agreement and Provider Authorization Form as part of the electronic data interchange setup process. All EDI trading partners must complete these forms to exchange PHI with Blue Cross.

Terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. You must update your provider authorization information if you send claims using a different submitter ID or route your 835 electronic remittance advice to a different unique receiver or trading partner ID. Updating the form ensures information is routed to the appropriate destination.

Whenever you switch vendors, billing services or clearinghouses, you need to update your provider authorization. To make changes to your EDI setup, visit bcbsm.com/providers and follow these steps:

• Click on Quick Links.
• Click on Electronic Connectivity EDI.
• Click on How to use EDI to exchange information with us electronically.
• Click on Update your Provider Authorization Form.

Review your provider authorization information if you’ve:

• Joined a new group practice
• Left a group practice and now bill using your own NPI
• Hired a new billing service
• Started submitting claims through a clearinghouse or you’ve changed clearinghouses
• Decided you no longer want to receive 835 files
• Selected a new destination for your 835 files

If you have questions about EDI enrollment, contact our Help Desk at 1-800-542-0945. For assistance with the Trading Partner Agreement and Provider Authorization Form, select the TPA option.

Comply with semiannual request to update or confirm demographic data

Blue Cross Blue Shield of Michigan and Blue Care Network members rely on our online provider directory for correct, up-to-date information. Twice each year, the Provider Enrollment and Data Management team sends you the demographic information we have on file for you with a request to update or confirm it.

Facilities that don’t respond to this mailing won’t appear in our online directory.

Make it a priority to:

• Respond to each request to update or confirm your demographic data.
• Update your demographic data throughout the year as needed.

If you need to make changes to your data, send them Provider Enrollment and Data Management by mail, fax or email:

• Mail: Provider Enrollment – Attestation
  20500 Civic Center Dr.
  Southfield, MI 48076-4115
  H200-PDA
• Fax: 1-844-216-4941
  Email: providerdataintegrity@bcbsm.com

Need help making changes or have questions? You’ve got options:

• Visit the Contact Us page of bcbsm.com/providers. (Scroll down to Update your information with us and select your provider type.)
• Call Provider Enrollment at 1-800-822 2761.

Use modifier 96 for habilitative services

Health care providers must use modifier 96 to identify any physical therapy, occupational therapy or speech-language pathology codes for habilitative services. This allows us to track when habilitative (versus rehabilitative) services are reported.

On Jan. 1, 2018, modifier SZ was deleted and can no longer be used for tracking habilitative services. Modifier 96 replaces modifier SZ.

Improve HEDIS scores, reduce medical record requests through proper claims coding

Submitting claims with CPT^® Category II and ICD-10 codes can help Blue Cross Blue Shield of Michigan determine if certain HEDIS^® measures are met without needing to review medical records. This lessens the administrative burden on office staff because it reduces the need for them to pull medical records for Blue Cross’ review.

CPT II codes that support select HEDIS measures include:

**The National Committee for Quality Assurance requires medical record review for the controlling high blood pressure measure. However, for the comprehensive diabetes care – blood pressure control measure, CPT Category II codes can be used to identify compliant members through claims data when the member’s latest blood pressure reading is compliant (<140/90).

ICD-10 codes that support HEDIS exclusion criteria include:

Patients will not be identified for certain HEDIS measures when ICD-10 exclusion codes are submitted on a claim. These include:

ICD-10 codes that support the adult BMI assessment measure include:

For more information on HEDIS measures, see our Clinical Quality Corner tip sheets. An article in this issue explains how to access them on web-DENIS.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance.

2018 Clinical Quality Corner tip sheets posted on web-DENIS

As you may have read in the May – June Hospital and Physician Update, we’ve updated our Clinical Quality Corner tip sheets for 2018.

The tip sheets are part of our ongoing efforts to give you the tools you need to improve health care quality. Each of the 27 tip sheets focuses on a specific HEDIS^® measure.

This year, they’ve been posted on both the BCBSM Provider Publications and Resources section of web-DENIS, as well as on the BCN Provider Publications and Resources section. Here’s one way to access them:

From the homepage of web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Click on Clinical Quality Corner on the left side of the page.

HEDIS^®, which stands for Healthcare Effectiveness Data and Information Set, is a registered trademark of the National Committee for Quality Assurance.

Talk with your patients about importance of complying with statin therapy

Several modifiable risk factors for cardiovascular disease are well-known and can be treated, including hyperlipidemia. Although treatments for hyperlipidemia, such as statin therapy, are effective and relatively inexpensive, many people aren’t controlling their condition adequately.

Talk with your patients about their risk factors associated with cardiovascular disease and the importance of complying with their statin treatment.

To read more about why statin therapy is beneficial for patients with cardiovascular disease, see the article in the July – August 2017 issue of Hospital and Physician Update, a Blue Cross Blue Shield of Michigan newsletter.

Did you know?
According to the Centers for Disease Control and Prevention:

• Heart disease is the leading cause of death for men and women in the U.S.
• An estimated one in every seven U.S. dollars spent on health care goes toward cardiovascular disease.
• This expenditure totals more than $300 billion in annual health care costs and lost productivity from premature deaths each year.

Coding corner: Diabetic eye disease

Patients with diabetes require ongoing medical care and monitoring to reduce the risk of complications, such as diabetic retinopathy, and improve outcomes. Clinical interventions go far beyond glycemic control.

Diabetic retinopathy
Diabetic retinopathy is caused by persistent high blood sugar levels that, over time, cause damage to the blood vessels in the retina. The blood vessels can swell, leak or close, which impairs the blood supply to the retina. In advanced cases, abnormal new blood vessels can grow on the retina, a process known as neovascularization, which results in loss of vision.

What should primary care doctors do?
Ensure that your diabetic patients have an annual dilated eye screening exam for diabetic eye diseases to prevent or delay blindness. Also, obtain a copy of the eye exam report from the ophthalmologist or optometrist and include it in the patient’s medical record.

Stages of diabetic eye disease

• Non-proliferative diabetic retinopathy: In this early stage, the blood vessels leak, making the retina swell and resulting in blurred vision
• Swelling of the macula (the central part of the retina) is known as macular edema; it’s the most common reason for vision loss among diabetics.
• Macular ischemia results when the blood supply to the macula is interrupted.
• Stages of NPDR range from mild to severe, with or without macular edema.

• Proliferative diabetic retinopathy: This advanced stage includes neovascularization, where the retina grows new abnormally fragile blood vessels, resulting in loss of vision.
• These new blood vessels often bleed into the vitreous, causing floaters or varying degrees of vision loss.
• The new blood vessels can also cause scar tissue to develop, resulting in problems with the macula and can lead to a detached retina.

Accurate documentation and coding
Health care providers should use the ICD-10-CM code Z13.5 (Encounter for screening for eye and ear disorders) until a definitive diagnosis has been determined by an eye care professional. Once definitively diagnosed, documentation and coding should be to the highest specificity of the disorder.

If primary care doctors receive no communication from the eye care professional but are aware of the presence of diabetic eye disease, they should document and code the condition to the highest specificity known to them. See the chart below for some examples.

**The seventh character is required for subcategories E11.32, E11.33, E11.34, E11.35 and E11.37 to designate laterality.

2018 updates to ICD-CM-10 Official Guidelines for Coding and Reporting

In Chapter 7, “Diseases of the Eye and Adnexa, Disorders of the Globe,” you’ll see a change to H42, Glaucoma in diseases classified elsewhere. The manual deletes the “excludes 2” note for glaucoma in diabetes mellitus and replaces it with an instructional note for appropriate sequencing that follows familiar coding conventions. The new note reads: “Code first glaucoma (in) diabetes mellitus (E08.39, E09.39, E10.39, E11.39, E13.39).”

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

FEP provides pregnancy care incentives, promotes healthy lifestyles

The Blue Cross and Blue Shield Federal Employee Program^® offers the Pregnancy Care Incentive Program to pregnant members and the Healthy Families programs for members with children.

The pregnancy care program encourages pregnant mothers to receive timely prenatal care and helps them make good choices to keep themselves and their babies healthy. It offers support and incentives during each stage of pregnancy. Eligible members can earn rewards toward a health account to be used for qualified expenses.

Once a child is born, FEP members can take advantage of the Healthy Families programs. These programs offer tools for developing healthy lifestyle habits from an early age, and address such topics as:

• Vaccination schedules
• Regular well-child visits
• Weight management strategies

We’ve made changes to Benefit Explainer

We’ve made changes to Benefit Explainer to make it easier for you to use.

On June 4, 2018, the Alerts — Form, General, Group and Topic — links and icons appeared in a larger, bold red typeface in the middle of the screen. This change affects the BPR, Medical/Payment Policy and Source Documents tabs in Benefit Explainer.

Below is an example of where the Alerts links and icons were located before the change in the BPR tab view.

Below is an example of where the Alerts links and icons are currently located in the BPR tab view.

Outpatient facilities added to Medicare Plus Blue prior authorization program

Beginning June 28, 2018, Blue Cross Blue Shield of Michigan expanded its prior authorization program for Medicare Plus Blue^SM PPO specialty medical medications that are billed on a professional claim form to include outpatient facilities, place of service 19, 22 and 24. Currently, only place of service 11 is part of this program.

What you need to know

• Select specialty medications are covered under the Medicare Part B medical benefit. The selected medications are not self-administered and must be administered (via injection or infusion) by a doctor or health care professional. In addition to current place of service 11, expansion to include outpatient facilities with place of service 19, 22 and 24 will begin June 28, 2018.
• Place of service definitions:
• 11 – Provider office
• 19 – Off-campus outpatient hospital
• 22 – On-campus outpatient hospital
• 24 – Ambulatory surgical center
• Prior authorization is required for professional claims submitted on an HCFA 1500 form or ANSI 837P electronic submission with place of service 11, 19, 22 and 24. Facility claims submitted using UB claim submission aren’t in scope for this expansion.
• Providers must obtain prior authorization and verify patient benefits to be eligible for payment for administering these services. If a prior authorization isn’t obtained before services are rendered, the claim will be denied for no authorization on file. At that time, a provider may submit a retroactive authorization request within 90 days of the date of service. Patient must meet all requirements and have the necessary coverage for the claim to be payable.
• Authorization isn’t a guarantee of payment. Benefits and eligibility must be determined at the time services are rendered.

Providers will submit Part B medical drug requests for dates of service electronically through NovoLogix^®, a secure online tool, on or after June 28, 2018. NovoLogix allows providers to obtain real-time status checks on prior authorizations and to obtain immediate approvals for certain medications when patients meet the criteria. Submitting these requests electronically is the preferred method because it saves time and allows you to view the status of the request at any time. If your patient has an existing prior authorization for a provider-administered drug on file, an additional authorization for place of service 19, 22 or 24 isn’t required.

Future notifications will be sent that will provide you with the date when you can begin entering cases through the medical prior authorization e-tool if the patient doesn’t have an existing prior authorization on file with the provider’s office.

Look for more information about NovoLogix training and other program details in future issues of The Record and on web-DENIS.

Six additional drugs to be added to commercial PPO 15-day Specialty Drug Limitation Program, starting Aug. 1

Starting Aug. 1, 2018, the following six drugs are being added to the Blue Cross Blue Shield of Michigan commercial PPO 15-Day Specialty Drug Limitation Program:

• Bosulif^®
• Caprelsa^®
• Exjade^®
• Erivedge^®
• Gilotrif^®
• Jadenu^®

Instead of a 30-day supply, we’ll limit all fills to a 15-day supply. This includes first fills and refills. Members will pay half of their copayment for a 15-day supply.

Blue Cross limits the day-supply quantity of a medication that a pharmacy can dispense to:

• Help save members money on copayments
• Reduce drug waste

We’ll add more drugs to the 15-day program throughout the year. Here’s the full list, including the six new drugs:

Authorization for Fasenra™ and Luxturna™ required for Medicare Advantage members starting in August

As communicated in a May web-DENIS message, for dates of service on or after Aug. 7, 2018, authorization will be required for the following Part B specialty drugs covered under the medical benefit for Medicare Plus Blue^SM PPO and BCN Advantage^SM members:

• Fasenra (benralizumab)
• Luxturna (voretigene neparvovec-rzyl)

Authorization for these drugs is already required for Blue Cross Blue Shield of Michigan and Blue Care Network commercial members.

For Medicare Plus Blue and BCN Advantage members, these medications require authorization when they are billed on a professional HCFA 1500 claim form or by electronic submission via ANSI 837P for these sites of care:

• Physician office (place of service 11)
• Outpatient facility (place of service 19, 22 and 24 for Medicare Plus Blue members and place of service 19 and 22 BCN Advantage members)

Authorization isn’t required for these medications when they are billed on a facility claim form, such as the UB-92, UB-04 or UCB.

You should bill both medications with procedure code J3590 and submit authorization requests for these medications through the NovoLogix online tool. Authorization must be obtained prior to administering the medications.

Commercial Medical Drug Prior Authorization Program adds Ilumya™

Starting Aug. 1, 2018, Ilumya (tildrakizumab-asmn) will be part of the Blue Cross Blue Shield of Michigan commercial Medical Drug Prior Authorization Program.

You can find information about the program by logging in to web-DENIS, clicking on BCBSM Provider Publications and Resources, and selecting Newsletters and Resources. Click Forms (under Other Resources), then Physician administered medications.

Keep in mind that the prior authorization requirement doesn’t apply to Federal Employee Program^® members.

The list below reflects all the medications in the program as of Aug. 1:

Reminder: Update Provider Authorization Form when changes occur with your 835 ERA routing destination

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of our members. These safeguards include completion of a Trading Partner Agreement and Provider Authorization Form as part of the electronic data interchange setup process. All EDI trading partners must complete these forms to exchange PHI with Blue Cross.

Terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. You must update your provider authorization information if you send claims using a different submitter ID or route your 835 electronic remittance advice to a different unique receiver or trading partner ID. Updating the form ensures information is routed to the appropriate destination.

Whenever you switch vendors, billing services or clearinghouses, you need to update your provider authorization. To make changes to your EDI setup, visit bcbsm.com/providers and follow these steps:

• Click on Quick Links.
• Click on Electronic Connectivity EDI.
• Click on How to use EDI to exchange information with us electronically.
• Click on Update your Provider Authorization Form.

Review your provider authorization information if you’ve:

• Joined a new group practice
• Left a group practice and now bill using your own NPI
• Hired a new billing service
• Started submitting claims through a clearinghouse or you’ve changed clearinghouses
• Decided you no longer want to receive 835 files
• Selected a new destination for your 835 files

If you have questions about EDI enrollment, contact our Help Desk at 1-800-542-0945. For assistance with the Trading Partner Agreement and Provider Authorization Form, select the TPA option.

Use modifier 96 for habilitative services

Health care providers must use modifier 96 to identify any physical therapy, occupational therapy or speech-language pathology codes for habilitative services. This allows us to track when habilitative (versus rehabilitative) services are reported.

On Jan. 1, 2018, modifier SZ was deleted and can no longer be used for tracking habilitative services. Modifier 96 replaces modifier SZ.

Here’s an update on Blue Distinction Specialty Care

We wanted to remind you about this important Blue Cross and Blue Shield Association designation program and let you know how the program has changed over the past year.

About the program
Blue Distinction^® Specialty Care recognizes health care facilities that demonstrate proven expertise in delivering high-quality, effective and cost-efficient care for select specialty areas. The program currently includes the following seven areas of specialty care:

• Bariatric surgery
• Cardiac care
• Knee and hip replacement
• Spine surgery
• Maternity care
• Cancer care
• Transplants

The program includes two levels of designation:

Blue Distinction Centers are providers recognized for their expertise in delivering safe, effective, high-quality specialty care.

Blue Distinction Centers+ are providers recognized for their expertise and cost-efficiency in delivering specialty care. Only those providers that first meet Blue Distinction Centers’ nationally established, objective quality criteria are considered for designation as a Blue Distinction Center+.

Recent program changes

• The complex and rare cancers program ended Dec. 31, 2017, and the new cancer care program launched Jan. 1, 2018. Here are features of the new program:
• There’s no restriction on cancer type
• Hospitals, physician groups and individual physicians can be designated.
• The provider must be engaged in a value-based payment arrangement with a Blue plan to be designated.
• There’s no BDC+ designation, only BDC.
• As of Jan. 1, 2018, the bariatric surgery program went from a type of service designation (stapling versus banding) to a place-of-service designation (comprehensive center versus ambulatory surgery center). This means that an entity can either be designated for bariatric surgery as a comprehensive center or as an ASC.

Program refreshes

• The Blue Cross and Blue Shield Association refreshes criteria for designation in each specialty area of the program about every two years to provide meaningful quality and cost differentiation to employers, employees and providers. To remain designated, facilities must reapply for Blue Distinction Center designations during each re-evaluation cycle.
• The spine surgery and knee and hip replacement programs are being refreshed this year. In the new cycle, ASCs can earn BDC designation in addition to hospitals. This summer, Blue Cross Blue Shield of Michigan will be sending a letter to each facility that performs these procedures, inviting them to apply for designation by submitting a provider survey. The refreshed programs are tentatively scheduled to be effective July 1, 2019.

Coming next

• A new fertility care program will launch Jan. 1, 2019.
• A new gene therapy and cellular immunotherapy program is tentatively scheduled to launch Jan. 1, 2019.
• A new substance use disorder program is tentatively scheduled to launch Jan. 1, 2020.

About selection criteria
Blue Distinction Center and Blue Distinction Center+ designations are awarded to facilities and providers based on a thorough, objective evaluation of their performance in the areas that matter most, including quality care, treatment expertise and overall patient results. Selection criteria are developed with the help of expert physicians and medical organizations. Blue Distinction Centers and Blue Distinction Centers+ have a proven history of delivering better quality and results, such as fewer complications and lower readmission rates, than those without these recognitions.

Finding a center
The Blue Distinction Specialty Care program provides broad national access to facilities and providers by delivering better quality specialty care, making them easy to find wherever you work and live across the U.S. You can easily locate a Blue Distinction Center at bcbs.com/blue-distinction-center-finder or by using our Find a Doctor feature at bcbsm.com.

Did you know?
Today, more than 3,600 Blue Distinction Center and Blue Distinction Center+ designations have been awarded to more than 1,900 health care facilities in 48 states.

Members who don’t meet criteria for covered services pay only the amount allowed by Blue Cross

When providers perform services that are covered under a member’s benefit plan but the coverage criteria isn’t met, the member is responsible for payment. However, the health care provider is obligated to accept the Blue Cross Blue Shield of Michigan allowed amount as payment in full.

This includes emergency department visits, ambulance services and non-cosmetic procedures. It doesn’t include services that aren’t covered under the benefit plan.

In addition, members are fully liable for any deductibles that haven’t been satisfied or if they failed to meet prior authorization requirements required by certain benefit plans. Again, their liability would be limited to the allowed amount for services that are covered under the benefit plan.

Our requirements for communicating the expected cost of services that aren’t part of the benefits under a plan haven’t changed.

Battling the opioid epidemic: A roundup of news and information

Campaign created to raise awareness of prescription drug abuse
Blue Cross Blue Shield of Michigan, the Michigan Health & Hospital Association, Michigan Osteopathic Association, the Michigan Open Prescribing Engagement Network and the Michigan State Medical Society recently teamed up to announce the “Be Rx SAFE” opioid awareness campaign. The campaign was created to raise awareness about the dangers of prescription drug abuse and overuse and encourage prescribers and patients to do their part in addressing the opioid crisis.

To learn more, read the MI Blues Perspective blog.

NIH doubles funding to develop scientific solutions to opioid crisis
At the 2018 National Rx Drug Abuse and Heroin Summit in April, the National Institutes of Health announced the launch of the Helping to End Addiction Long-term Initiative, or HEAL. As part of its effort to speed scientific solutions to stem the national opioid public health crisis, NIH is nearly doubling funding for research on opioid misuse, addiction and pain — from approximately $600 million in 2016 to $1.1 billion in 2018. The initiative has two main objectives: preventing addiction through enhanced pain management and improving treatments for opioid misuse disorder and addiction.

More information is available in the NIH news release.

New opioid treatment program tested for BCN members
A new clinical pilot program will test a comprehensive treatment model that Dr. William Beecroft, medical director for Blue Care Network, hopes will yield better results for members struggling with addiction. The program is called CLIMB, which stands for Community-based Life-changing Individualized Medically-assisted evidence-Based treatment program. It kicked off May 1 for 250 BCN and BCN Advantage^SM members. The 12-month pilot project will serve members at Pine Rest Christian Mental Health Services near Grand Rapids and at the Henry Ford Maplegrove Center in Bloomfield Hills.

Click here for more information.

Blue Cross, Walgreens team up to promote safe medication disposal
Blue Cross Blue Shield of Michigan and Walgreens have joined forces to make it easy and safe to dispose of unwanted medications with year-round medication disposal kiosks at 20 Walgreens pharmacies across the state. This is a convenient way to dispose of unused medications, including opioids and other controlled substances, and ensure they don’t fall into the wrong hands. The kiosks at select Walgreens pharmacies are available during regular pharmacy hours. The program began in 2016 and was recently expanded to include additional stores nationwide.

For more information and a list of the Walgreens kiosk locations in Michigan, see the May issue of Value Partnerships Update.

New online resource available to help curb opioid epidemic
Blue Cross Blue Shield of Michigan recently developed a website, mibluesperspectives.com/opioids101, to educate our members and the general public about the opioid epidemic, show what Blue Cross and its participating health care providers have done to tackle the problem, what we plan to do going forward and how the community can help. This easy-to-use website includes a wealth of resources that can be shared with patients and family members.

HCPCS update: New codes added

The Centers for Medicare & Medicaid Services has added several new codes as part of its quarterly Health Care Procedure Coding System updates. The codes, effective dates and Blue Cross Blue Shield of Michigan’s coverage decisions are below.

Medicine supplementary — Injections

Medicine supplementary — Durable medical equipment

Medicine supplementary (anti-hemophilia drugs) — Injections

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

Effective July 1, use new procedure code Q9995 for anti-hemophilia drug

The Center for Medicare & Medicaid Services has established a procedure code for emicizumab-kxwh, effective July 1, 2018.

When reporting injection services for this drug that were performed from Nov. 16, 2017, through June 30, 2018, continue to use code J7199. All injection services performed on or after July 1, 2018, must be reported with procedure code Q9995.

Emicizumab-kxwh continues to be covered for FDA-approved indications as established on Nov. 16, 2017. The U.S. Food and Drug Administration has approved this drug for use in preventing or reducing frequency of bleeding episodes in adults and pediatric patients who:

• Have hemophilia A
• Have developed antibodies called Factor VIII inhibitors via subcutaneous injection

This drug doesn’t require prior authorization from Blue Cross Blue Shield of Michigan.

Effective July 1, use new procedure code Q9993 when billing for Zilretta^®

Effective July 1, 2018, the Center for Medicare & Medicaid Services has established a new procedure code for Zilretta, or triamcinolone acetonide.

All injection services for Zilretta from Oct. 9, 2017, through June 30, 2018, will continue to be reported with procedure code J3490. All injection services performed on or after July 1, 2018, must be reported with procedure code Q9993.

The National Drug Code for Zilretta is 70801-0003-01.

Zilretta continues to be covered for the FDA-approved indications as establisted on Oct. 9, 2017. The U.S. Food and Drug Administration approved Zilretta for the management of osteoarthritis pain of the knee.

This drug doesn’t require prior authorization from Blue Cross Blue Shield of Michigan.

Billing chart: Blues highlight medical, benefit policy changes

You’ll find the latest information about procedure codes and Blue Cross Blue Shield of Michigan billing guidelines in the following chart.

This billing chart is organized numerically by procedure code. Newly approved procedures will appear under the New Payable Procedures heading. Procedures for which we have changed a billing guideline or added a new payable group will appear under Updates to Payable Procedures. Procedures for which we are clarifying our guidelines will appear under Policy Clarifications. New procedures that are not covered will appear under Experimental Procedures.

You will also see that descriptions for the codes are no longer included. This is a result of recent negotiations with the AMA on use of the codes.

We will publish information about new BCBS groups or changes to group benefits under the Group Benefit Changes heading.

For more detailed descriptions of the BCBSM policies for these procedures, please check under the Medical/Payment Policy tab in Explainer on web-DENIS. To access this online information:

• Log in to web-DENIS.
• Click on BCBSM Provider Publications & Resources.
• Click on Benefit Policy for a Code.
• Click on Topic.
• Under Topic Criteria, click on the drop-down arrow next to Choose Identifier Type and then click on HCPCS Code.
• Enter the procedure code.
• Click on Finish.
• Click on Search.

Six additional drugs to be added to commercial PPO 15-day Specialty Drug Limitation Program, starting Aug. 1

Starting Aug. 1, 2018, the following six drugs are being added to the Blue Cross Blue Shield of Michigan commercial PPO 15-Day Specialty Drug Limitation Program:

• Bosulif^®
• Caprelsa^®
• Exjade^®
• Erivedge^®
• Gilotrif^®
• Jadenu^®

Instead of a 30-day supply, we’ll limit all fills to a 15-day supply. This includes first fills and refills. Members will pay half of their copayment for a 15-day supply.

Blue Cross limits the day-supply quantity of a medication that a pharmacy can dispense to:

• Help save members money on copayments
• Reduce drug waste

We’ll add more drugs to the 15-day program throughout the year. Here’s the full list, including the six new drugs:

Authorization for Fasenra™ and Luxturna™ required for Medicare Advantage members starting in August

As communicated in a May web-DENIS message, for dates of service on or after Aug. 7, 2018, authorization will be required for the following Part B specialty drugs covered under the medical benefit for Medicare Plus Blue^SM PPO and BCN Advantage^SM members:

• Fasenra (benralizumab)
• Luxturna (voretigene neparvovec-rzyl)

Authorization for these drugs is already required for Blue Cross Blue Shield of Michigan and Blue Care Network commercial members.

For Medicare Plus Blue and BCN Advantage members, these medications require authorization when they are billed on a professional HCFA 1500 claim form or by electronic submission via ANSI 837P for these sites of care:

• Physician office (place of service 11)
• Outpatient facility (place of service 19, 22 and 24 for Medicare Plus Blue members and place of service 19 and 22 BCN Advantage members)

Authorization isn’t required for these medications when they are billed on a facility claim form, such as the UB-92, UB-04 or UCB.

You should bill both medications with procedure code J3590 and submit authorization requests for these medications through the NovoLogix online tool. Authorization must be obtained prior to administering the medications.

Commercial Medical Drug Prior Authorization Program adds Ilumya™

Starting Aug. 1, 2018, Ilumya (tildrakizumab-asmn) will be part of the Blue Cross Blue Shield of Michigan commercial Medical Drug Prior Authorization Program.

You can find information about the program by logging in to web-DENIS, clicking on BCBSM Provider Publications and Resources, and selecting Newsletters and Resources. Click Forms (under Other Resources), then Physician administered medications.

Keep in mind that the prior authorization requirement doesn’t apply to Federal Employee Program^® members.

The list below reflects all the medications in the program as of Aug. 1:

Clarification: Requirements for providers billing DME prosthetics, orthotics and supplies

All durable medical equipment and medical supply providers that bill for custom prosthetic and orthotic services (including professional providers that meet Centers for Medicare & Medicaid Services exemption requirements) will be required to bill Blue Cross Blue Shield of Michigan claims with a separate, valid prosthetic and orthotic supplier provider PIN.

Although CMS allows for payment using only one provider DMEPOS NPI, effective July 1, 2018, Blue Cross will require a separate P&O provider NPI for billing custom P&O and a DME provider NPI for billing DME and off-the-shelf P&O services. All claims must include your NPI and the taxonomy code affiliated with your DMEPOS supplier number.

If you have a 10-digit DMEPOS supplier number, also known as a DMEPOS provider transaction access number, from the National Supplier Clearinghouse, and you bill for custom P&O HCPCS codes, submit a copy to Blue Cross’ Provider Enrollment and Data Management to request registration as a P&O provider. If you aren’t a registered P&O provider, your claims for custom P&O services will be rejected as not payable to your provider specialty and you’ll be liable for any costs.

Contact Provider Enrollment and Data Management at 1-800-822-2761 for more information to update your provider enrollment status.

Additional codes added to capped rental list

Effective Sept. 1, 2018, Blue Cross Blue Shield of Michigan is removing more than 50 HCPCS codes from the purchase-only list and adding them to the capped rental list. Click here to see the updated list of capped rental HCPCS codes, with the newly added codes bolded. To see the list of purchase-only codes, click here.